Complex Regional Pain Syndrome

1. COMPLEX REGIONAL
PAIN SYNDROME (CRPS)
Dr. Afroz Shaikh
M.P.T in Musculoskeletal Sciences

2. SYNONYMS FOR CRPS:
• Reflex sympathetic dystrophy
• Shoulder hand syndrome
• Sudeck‘s atrophy
• Algodystrophy
• Post traumatic sympathetic dystrophy
• Sympathetic neurovascular dystrophy

3. DEFINITION
• It is defined as pain state maintained by sympathetic efferent activation by
circulating catecholamine, or by neurochemical action.

4. Characteristics of both the type :
Type 1
• The Presence of an initiating noxious
event or a cause for immobilization
• Continuing pain and allodynia which is
disproportionate to any inciting event
• Evidence at some time of oedema,
changes in skin blood flow,abnormal
sudomotor activity in the region of pain
• Circumferential in distribution
Type 2
• Continuing pain, allodynia or
hyperalgesia after nerve injury, not
necessarily limited to the distribution of
the injured nerve
• Evidence at some time of oedema,
changes in skin blood flow,abnormal
sudomotor activity in the region of pain
• Follows discrete nerve distribution

5. Type 1
• The diagnosis is excluded by the
existence of other conditions that can
account for the degree of pain &
dysfunction
• Good response to sympathetic blocks
• No response to nerve blocks
• Both mechanical & thermal allodynia
Type 2
• The diagnosis is excluded by the
existence of other conditions that can
account for the degree of pain &
dysfunction
• Variable response to sympathetic blocks
• Responds well to nerve blocks
• Mechanical allodynia

6. EPIDEMIOLOGY
• Incidence of 26 in 100,000
• Females are more affected than male (3.5:1)
• Peak incidence in the age group of 55-70 years
• Fracture is more common precipitating factor
• CRPS 1 is more common than CRPS 2

7. Complex regional pain syndrome can develop after different types of injuries, such
as:
• sprains and strains
• surgeries
• fractures
• contusions
• crush injuries
• nerve lesions
• stroke

8. PATHOPHYSIOLOGY

9. SYMPTOMS AND SIGNS
Predominant symptom : Pain out
of proportion to the initial injury
Primary signs:
• Severe hyperalgesia
• Oedema
• Stiffness

10. Secondary Signs:
• Osteopenia
• Sudomotor or vasomotor changes(mottling, discoloration)
• Temperature changes
• Trophic changes
• Palmar fibrosis
• Hyperhydrosis

11. • Skin changes
• Loss of skin creases
• Loss of hair
• Decreased moisture
• Dystonic posture of affected limb

12. PATTERNS OF SPREADING SYMPTOMS
• A “continuity type” of spread where the symptoms spread upward from
the initial site, e.g. from the hand to the shoulder.
• A “mirror-image type” where the spread was to the opposite limb.
• An “independent type” where symptoms spread to a separate ,distant
region of the body. This type of spread may be spontaneous or related to a
secondary trauma.
• Total body RSD

13. STAGES OF CRPS

18. THREE PHASE BONE SCANNING
• Description - Radionucleotide imaging scintigraphy employing
radiopharmaceutical technetium coupled to a phosphate complex has been
used to help facilitate the diagnosis of CRPS-1. It was hoped that a three-
phase radionucleotide study would be selective in the face of
demineralization of the bone as seen in CRPS-I. However, there are many
different types of conditions that can produce osteoporosis and a triple-
phase bone scan does not distinguish between the causes of bone
demineralization.

19. • Results - Clinical information can be derived from each of the three phases of the
bone scan following injection. In the early course of CRPS-I, there is an
increased uptake seen during Phase 1. However, in the late course of the disease
process, there can actually be a decreased uptake seen. In Phase 2, which reflects
the soft tissue vascularity, an increased diffuse uptake may be appreciated during
the early course of CRPS-I. During Phase 3, one will see a diffuse uptake of
multiple bone involvement of the involved limb, reflecting the bone turnover
secondary to osteoporosis. Negative bone scans may be found in up to 40
percent of patients clinically diagnosed with CRPS-I; however, when positive it
may help to confirm the diagnosis of CRPS-I.

21. RADIOGRAPHY
• Description - A radiological finding in CRPS may be unilateral osteoporosis;
however, osteoporosis may be absent in many cases. In CRPS-I, the osteoporosis
may be rapid in progression. The disorder typically affects the distal part of an
extremity such as a phalanges, hand or foot; however intermediate joints such as
the knee or elbow may be involved. Contralateral x rays should be taken for
comparison and should include the distal phalanges.
• Results - The radiological appearance of osteoporosis has been characterized as
spotty or patchy. Although CRPS-I may exist in the absence of osteoporosis, the
diagnosis of CRPS-I cannot be made solely on the basis of radiographic
appearance or the osteoporosis alone.

22. THERMOGRAPHY
• Description –There is good evidence that CRPS is characterized by inhibition of
sympathetic cutaneous responses on the affected side and by blunted sympathetic
response to physiologic stimuli. Based on the relatively common finding of
temperature discrepancy in non-CRPS patients with chronic pain, a stress test
thermogram should be used. Infrared thermography may be useful for patients
with suspected CRPS-I and II, and SMP. Thermography can distinguish
abnormal thermal asymmetry of 1.0 degree Celsius which is not distinguishable
upon physical examination. It may also be useful in cases of suspected small
caliber fiber neuropathy and to evaluate patient response to sympatholytic
interventions.

23. • Cold Water Stress Test (Cold Pressor Test)
• Warm Water Stress Test
• Whole Body Thermal Stress

24. AUTONOMIC TEST BATTERY
• Description – Resting skin temperature (RST), resting sweat output
(RSO), and quantitative sudomotor axon reflex test (QSART) are a
generally accepted test battery. There is good evidence that CRPS is
characterized by inhibition of sympathetic cutaneous responses on the
affected side and by blunted sympathetic response to physiologic stimuli.
The tests can provide additional information regarding malfunction of the
sympathetic system and the diagnosis of CRPS. Prior authorization is
required. As with all diagnostic testing, the results must be interpreted in
relationship to the patient’s signs and symptoms

25. ELECTRODIAGNOSTIC TESTING
• Electromyography (EMG) and Nerve Conduction Studies (NCS) are
generally accepted, well-established and widely used.

26. MANAGEMENT
Medications
• Anti inflammatory like Oral Steroids
• Antidepressives
• Vasodilators
• COX inhibitors such as piroxicam
• GABA analogs such as gabapentin and pregabaline

27. Blocks
• Local anesthetic block
• Stellate ganglion block
• Lumbar block

28. • Surgeries : Sympathectomy
Surgical, chemical or radiofrequency sympathectomy – Interruption of
affected part of sympathetic nervous system

29. PT MANAGEMENT
• Pain : Hot pack or Ice pack (Avoid extreme temperature)
• Edema :Elevation of extremity & Place the hand in a position of function
• Allodynia : Graded motor imagery
• Dystonia and joint stiffness: Motor re-education and strengthening,
mobilize other areas of the extremities, active and active-assisted motion ,
massage, compression garments & splinting